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This winter is brutal. The cold weather has made it hard to socialize outdoors, coronavirus variants are spreading, and the US is about to surpass half a million Covid-19 deaths. Many of us are feeling anxious about how we’re going to make it through the lonely, bleak weeks ahead.
I see a lot of people trying to cope with this anxiety by drumming up one-off solutions. Buy a fire pit! Better yet, buy a whole house! Those may be perfectly fine ideas, as far as they go — but I’d like to suggest a more effective way to think about reducing your suffering and increasing your happiness this winter.
Instead of thinking about the myriad negative feelings you want to avoid and the myriad things you can buy or do in service of that, think about a single organizing principle that is highly effective at generating positive feelings across the board: Shift your focus outward.
“Studies show that anything we can do to direct our attention off of ourselves and onto other people or other things is usually productive and makes us happier,” said Sonja Lyubomirsky, a psychology professor at the University of California Riverside and author of The How of Happiness: A Scientific Approach to Getting the Life You Want. “A lot of life’s problems are caused by too much self-focus and self-absorption, and we often focus too much on the negatives about ourselves.”
Rather than fixating on our inner worlds and woes, we can strive to promote what some psychologists call “small self.” Virginia Sturm, who directs the Clinical Affective Neuroscience lab at the University of California San Francisco, defines this as “a healthy sense of proportion between your own self and the bigger picture of the world around you.”
This easy-to-remember principle is like an emotional Swiss Army knife: Open it up and you’ll find a bunch of different practices that research shows can cut through mental distress. They’re useful anytime, and might be especially helpful during this difficult winter (though they’re certainly no panacea for broader problems like mass unemployment or a failed national pandemic response).
The practices involve cultivating different states — social connectedness, a clear purpose, inspiration — but all have one thing in common: They get you to focus on something outside yourself.
A sense of social connectedness
Some of the practices are about cultivating a sense of social connectedness. Decades of psychology research have taught us that this is a key to happiness.
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In fact, Lyubomirsky said, “I think it is the key to happiness.”
That’s what Harvard’s Study of Adult Development discovered by following the lives of hundreds of people over 80 years, from the time they were teenagers all the way into their 90s. The massive longitudinal study revealed that the people who ended up happiest were the ones who really leaned into good relationships with family, friends, and community. Close relationships were better predictors of long and pleasant lives than money, IQ, or fame.
Psychiatrist George Vaillant, who led the study from 1972 to 2004, summed it up like so: “The key to healthy aging is relationships, relationships, relationships.”
Other studies have found evidence that social connections boost not only our mental health but also our physical health, helping to combat everything from memory loss to fatal heart attacks.
During our pandemic winter, you can socialize in person by, yes, gathering around a fire pit or maybe doubling your bubble. But there are other ways to make you feel you’re connected to others in a wider web. A great option is to perform an act of kindness — like donating to charity, or volunteering to read to a child or an older person online.
“I do a lot of research on kindness, and it turns out people who help others end up feeling more connected and become happier,” Lyubomirsky told me.
Lyubomirsky’s research shows that committing any type of kind act can make you happier, though you should choose something that fits your personality (for example, if you don’t like kids, then reading to them might not be for you). You may also want to vary what you do, because once you get used to doing something, you start taking it for granted and don’t get as much of a boost from it. By contrast, people who vary their kind acts show an increase in happiness immediately afterward and up to one month later. So you might call to check up on a lonely friend one day, deliver groceries to an older neighbor the next day, and make a donation the day after that.
A sense of purpose
Other practices are about cultivating a sense of purpose. Psychologists have found that having a clear purpose is one of the most effective ways to cope with isolation.
Steve Cole, a researcher at the University of California Los Angeles, studies interventions designed to help people cope with loneliness. He’s found that the ones that work tend to focus not on decreasing loneliness, but on increasing people’s sense of purpose. Recalling one pilot program that paired isolated older people with elementary school kids whom they’re asked to tutor and look out for, Cole told Vox, “Secretly, this is an intervention for the older people.”
Philosophers have long noted the fortifying effects of a clear sense of purpose. “Nietzsche said if you find purpose in your suffering, you can tolerate all the pain that comes with it,” Jack Fong, a sociologist who researches solitude at California State Polytechnic University, Pomona, told me. “It’s when people don’t see a purpose in their suffering that they freak out.”
Experienced solitaries confirm this. Billy Barr, who’s been living alone in an abandoned mining shack high up in the Rocky Mountains for almost 50 years, says we should all keep track of something. In his case, it’s the environment. How high is the snow today? What animals appeared this month? For decades, he’s been tracking the answers to these questions, and his records have actually influenced climate change science.
Now, he suggests that people get through the pandemic by participating in a citizen science project such as CoCoRaHS, which tracks rainfall.
“I would definitely recommend people doing that,” he told WAMU. “You get a little rain gauge, put it outside, and you’re part of a network where there’s thousands of other people doing the same thing as you, the same time of the day as you’re doing it.” (Notice, again, that this is really about sensing you’re part of the larger world around you.)
Other citizen science projects are looking for laypeople to classify wild animals caught on camera or predict the spread of Covid-19.
If citizen science isn’t your jam, find something else that gives you a sense of purpose, whether it’s writing that novel you’ve been kicking around for years, signing up to volunteer with a mutual aid group, or whatever else.
A sense of inspiration
Finally, some practices are about cultivating a sense of inspiration — which can take the form of gratitude, curiosity, or awe.
Regularly feeling gratitude helps protect us from stress and depression.
“When you feel grateful, your mind turns its attention to what is perhaps the greatest source of resilience for most humans: other humans,” David DeSteno, a psychology professor at Northeastern University and the author of Emotional Success, told me. “By reminding you that you’re not alone — that others have contributed to your well-being — it reduces stress.”
So one thing you can do this winter is try gratitude journaling. This simple practice — jotting down things you’re grateful for once or twice a week — has gained popularity over the past few years. But studies show there are more and less effective ways to do it. Researchers say it’s better to write in detail about one particular thing, really savoring it, than to dash off a superficial list of things. They recommend that you try to focus on people you’re grateful to, because that’s more impactful than focusing on things, and that you focus on events that surprised you, because they generally elicit stronger feelings of thankfulness.
Another practice is to write a letter of gratitude to someone. Research shows it significantly increases your levels of gratitude, even if you never actually send the letter. And the effects on the brain can last for months. In one study, subjects who participated in gratitude letter writing expressed more thankfulness and showed more activity in their pregenual anterior cingulate cortex — an area involved in predicting the outcomes of our actions — three months later.
Feeling a sense of curiosity or awe about the world around you is likewise shown to boost emotional well-being.
“Awe makes us feel like our problems are very trivial in the big scheme of things,” Lyubomirsky said. “The idea that you are this tiny speck in the universe gives you this bigger-picture perspective, which is really helpful when you’re too self-focused over your problems.”
For example, a study recently published in the journal Emotion investigated the effects of “awe walks.” Over a period of eight weeks, 60 participants took weekly 15-minute walks outdoors. Those who were encouraged to seek out moments of awe during their walks ended up showing more of the “small self” mindset, greater increases in daily positive emotions, and greater decreases in daily distress over time, compared to a control group who walked without being primed to seek out awe.
“What we show here is that a very simple intervention — essentially a reminder to occasionally shift our energy and attention outward instead of inward — can lead to significant improvements in emotional wellbeing,” said Sturm, the lead author.
So, bottom line: When the world between your two ears is as bleak as the howling winter outside, shifting your attention outward can be powerfully beneficial for your mental health. And hey, even in the dead of winter, a 15-minute awe walk outdoors is probably something you can do.
If you or anyone you know is anxious, depressed, upset, or needs to talk, there are people who want to help. Text CRISIS to 741741 for free, confidential crisis counseling.
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We’ve reached half a million deaths from the coronavirus in the US. But most of these deaths — and the grueling medical ordeals leading up to them — have remained largely hidden from view. The majority of terminally ill Covid-19 patients typically spend their last days or weeks isolated in ICUs to keep the virus from spreading.
“Most of what I’m seeing is behind closed curtains, and the general public isn’t seeing this side of it,” says Todd Rice, a critical care and pulmonology specialist at Vanderbilt University Medical Center. Even “families are only seeing a little bit of it,” he says. As a result, most of us have been “protected and sheltered from seeing the worst of this disease.”
So what have these 500,000 people endured as the infection took over and their bodies failed? The terrible details have been strikingly absent from most of our personal and national discussions about the virus. But if we have been thus far (perhaps somewhat willfully) blind to the excruciating ways Covid-19 takes lives, this milestone is an opportunity to open our eyes.
Four physicians, who collectively have cared for more than 100 dying Covid-19 patients over the past 11 months, shared with Vox what their patients have gone through physically and mentally as the virus killed them. Their experiences reveal the isolating and invasive realities of what it is typically like for someone to die from Covid-19.
Lungs “full of bees” and a “sense of impending doom”
The torture of Covid-19 can begin long before someone is sick enough to be admitted to a hospital intensive care unit.
Since the coronavirus attacks the lungs, it hampers the intake of oxygen. People with worsening Covid-19 typically show up in the emergency room because they are having trouble breathing.
As their lungs deteriorate further, they have a harder and harder time getting enough oxygen with each breath, meaning they need to breathe faster and faster — up from an average of about 14 times per minute to 30 or 40. Such gasping can bring about a very real sense of panic.
Imagine trying to breathe through a very narrow straw, says Jess Mandel, chief of pulmonary, critical care, and sleep medicine at UC San Diego Health. “You can do that for 15 to 20 seconds, but try doing it for two hours.” Or for days or weeks.
Patients struggling through low oxygen levels like this have told Kenneth Remy, an assistant professor of critical care medicine at Washington University School of Medicine in St. Louis, that it feels like a band across their chest or that their lungs are on fire. Or like a thousand bees stinging them inside their chest. Others might have thick secretions in their lungs that make it feel like they are trying to breathe through muck. Many people say it feels like they’re being smothered.
The ordeal is so taxing that many wish for death. “You hear the patients say, ‘I just want to die because this is so excruciating,’” Remy says. “That’s what this virus does.”
Others feel that death is coming no matter what they do. Rice notes that is much more so for his Covid-19 patients than others he has treated. There seems to be something about Covid-19, he says, “that makes people prone to having a feeling of, ‘I really believe I’m going to die.’”
Meilinh Thi, who specializes in critical care and pulmonology at the University of Nebraska Medical Center, has witnessed the same thing. “A lot of patients, regardless of age, have this sense of impending doom,” Thi says. Many have told her outright they felt like they were going to die. Eerily, “Everyone who has told me that has passed away,” she says.
Isolated
The agony of being critically ill with Covid-19 isn’t just borne by the body but also by the mind. “It doesn’t only put your lungs on fire or give you a horrible headache or make you feel miserable or make you breathe really fast,” Remy says. “It also wreaks havoc on your mental state.”
For one, from the time anyone with Covid-19 is admitted to the hospital, they are essentially cut off from almost everything that is familiar. Most Covid-19 deaths have occurred in hospitals, but Centers for Disease Control and Prevention data shows that some are also dying in long-term care facilities (about 10 percent) or at home (about 6 percent).
“A lot of patients have told me how isolating and how lonely it is,” Thi says. And many get depressed. It is also incredibly scary to reach that point of illness with a disease that we know has already killed so many people, she and others point out.
All of these challenges have a cumulative effect. “If you can understand being in the hospital for two, three weeks, continuously breathing that fast, not having good interactions with your family because they can’t come and visit you — it’s extremely anxiety-provoking. It’s scary,” Remy says.
Being in the ICU for any reason also vastly increases a person’s risk for delirium, a state of confusion that can result in agitation, fear, and anger. Medications used to sedate people or relieve pain (both common in Covid-19 treatment) are part of the reason for this risk, as are the constant monitoring and physical disturbances — and subsequent sleep disruption.
Being a Covid-19 patient increases this likelihood of disorientation even more. Some estimates put the rate of delirium among adult ICU Covid-19 patients at about 65 percent.
One reason for this extra risk is that the only people patients see are covered in head-to-toe PPE, often with only their eye area visible behind a shield or goggles, rendering them even more anonymous and unfamiliar. (ICU nurses have described working alongside the same people for decades and now not recognizing them due to all the protective gear.) “That for sure increases the risk of delirium,” Thi says.
As a Covid-19 patient, “You’re just devoid of human contact to a large degree,” Mandel says.
And that is no small thing. With loved ones relegated to video calls, personal connection through in-person visits — typically a mainstay during an intensive hospital stay — is gone.
“If your mom or dad or spouse was in the hospital and was very sick, you would be at their bedside holding their hand,” Remy says. With fatal Covid-19, your last meaningful contact with family, before your final hours, might be as you get admitted into the ER, days or weeks before.
Doctors often have to use many invasive procedures to try to save lives
Anyone unwell enough to be in the ICU for any reason will be hooked up to lots of machines. But people with severe Covid-19 face a particularly grueling and invasive experience.
When people can no longer breathe for themselves and still aren’t getting enough oxygen from external sources (like short nose tubes or a BiPap machine, like those some people wear for sleep apnea), the next step is usually putting them on a ventilator.
To do this, patients are put on IV-based sedation and pain medication so they can tolerate the procedure. A tube is inserted into the mouth and down the airway so the machine can pump air into the lungs. The tube can remain there for days or weeks, during which time that person will remain heavily sedated and unable to talk. (This sedation can also mask other problems that arise during their illness, such as major strokes.)
Those who have survived the ordeal often don’t even remember the day leading up to being put on ventilation, Thi says. “They say they really just lost that portion of their life.”
The ventilator itself is not without risks. For example, if the machine is set to deliver too much air, it can cause additional lung damage. And the breathing tube only tends to be safe to keep in place for about two to three weeks, Thi notes. After that, it can start to deteriorate. At that point, doctors might surgically insert a tube into the patient’s neck — a procedure known as a tracheostomy — to connect them to the ventilator.
For some, even mechanical ventilation can’t get them enough oxygen. These patients often get put on “heart-lung” machines, which pump blood out of the body, through a machine that oxygenates it, and back in. (These are also sometimes used for people who have suffered a heart attack, and are known to have numerous side effects, such as increased risk for strokes as well as for agitation and delirium.) This process requires two large catheters (long tubes) inserted into a major artery or vein, so the machine can effectively pump enough blood in and out of the body.
Flipping people onto their stomachs has also helped get more air into their systems. During this practice, called proning, the sick individual is typically put on a medication to paralyze them so they cannot move. (Medical staff also turn incapacitated patients in bed every couple of hours “to make sure their skin doesn’t break down,” Thi says.)
A significant proportion of people — somewhere between about 1 in 5 and 1 in 3 — who get very sick with Covid-19 also end up with kidney failure. To prevent this from killing them, they’re put on dialysis machines, which take blood out of the body and filter it before returning it to the body. This procedure can cause nausea, cramping, and chronic itching. Anyone getting dialysis will need two additional large catheters put into another major blood vessel.
But these aren’t all of the tubes critically ill Covid-19 patients need. They also have a central venous catheter to administer medication. This long tube usually gets inserted into a major vein in the clavicle or groin, then is pushed through the vein until it reaches the heart, where it will stay until that person recovers or dies. Another catheter, sometimes put in near the groin, will take the person’s blood for analysis.
Other catheters will be inserted into the urethra to drain urine (which is monitored closely) and the rectum to frequently evacuate their feces (which is especially important because Covid-19 often causes diarrhea). Additional IVs, such as for hydration and medications, will poke patients in smaller vessels as well. People this ill with Covid-19 will also have a tube put into their mouth or nose and down into their stomach, to deliver a nutritious slurry to prevent malnutrition.
On top of all of these tubes and needles, a number of other beeping and humming devices monitor a person’s vitals. Leads attached to the chest track heart function, and a pulse oximeter on the finger keeps tabs on oxygen saturation. A standard cuff monitors blood pressure, but people often get an additional catheter into yet another vessel to measure blood pressure from within that artery.
All of these incredibly invasive interventions have a goal of sustaining the body simply so that it can try to fight off the virus and heal. “The technology we have is very powerful in terms of keeping people alive but less powerful at turning things around,” Mandel says. “It’s always a race.”
But even all of these procedures — alongside treatments like dexamethasone and remdesivir — are not enough to save everyone with Covid-19. Some people decline to go through some or all of this, or at least to endure it indefinitely, but that does not guarantee a lack of suffering. And for those most unlucky 1.8 percent of people confirmed to have Covid-19 in the US, death will then be imminent.
The end
Once someone is sick enough with Covid-19 that they need a ventilator, their chance of survival is somewhere between 40 and 60 percent, notes Remy. “You flip a coin, and you may be one of those people who die,” he says.
Remy recalls one particularly difficult week during the fall surge when he cared for a number of people in their 40s and 50s who ultimately died. Most of them were obese but otherwise healthy when they caught Covid-19 by not wearing a mask.
“One of the[se] patients specifically told me before I put the breathing tube in, ‘Let everyone know that this is real, my lungs are on fire. It’s like there’s bees stinging me. I can’t breathe. Please let them know to wear a mask … because I wouldn’t wish this on my worst enemy.’”
Right after that patient died, Remy made a precautionary video that he posted on Twitter.
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If a patient’s breathing deteriorates slowly, hospitals can often arrange a way for them to talk with family members before they get intubated. Because after the tube goes in, they might not be conscious or able to talk again before they die. Regardless, the last person they have conscious contact with is typically a member of the medical staff before they are heavily sedated to receive the ventilator tube. In essence, “It could be anybody,” Rice says.
Despite the strict isolation for Covid-19 patients, “We try to make sure patients don’t die alone,” Thi says. For those who quickly nosedive, there often isn’t time to bring in family. Those people die surrounded by medical staff, either receiving CPR or, if they had do not resuscitate orders, with staff standing by.
For those who fall toward death, family — in full PPE — are now typically allowed in (which wasn’t usually the case at the beginning of the pandemic). At that point, “We would proceed with comfort measures only,” Thi says. In this scenario, the dying person will be on heavy medication as the ventilator tube is removed. Even still, once it gets taken out, people often gasp or cough as the body fights for air before they die.
Despite the palliative care and the possibility for family to now be present for a person’s actual death, doctors describe Covid-19 as a uniquely terrible way to die. “Covid is just so different,” Thi says. “I don’t think anything could be comparable to it. … I don’t wish it on my worst enemy.”
Remy agrees. After having cared for patients dying from infectious diseases all over the world, he says, “I don’t know a disease that wreaks such havoc on the body and on the mind.” Which is perhaps why his dying patient was pleading with him so desperately just before being intubated to tell people to wear their masks and take the virus seriously.
Because otherwise, it will continue to take thousands of lives this way each day in the US until we can get vaccines to almost everyone.
Katherine Harmon Courage is a freelance science journalist and author of Cultured and and Octopus! Find her on Twitter at @KHCourage.
The power was still out in my Dallas housing complex early last Tuesday, so I grabbed the survival hatchet from my emergency bag to chop up a couple of fallen trees, which were covered with six inches of down-soft snow dropped by Winter Storm Uri.
The trees broke easily, and after 30 minutes of hacking, I’d cut enough for two small blazes. I divided the wood — one half for my apartment, the other for my neighbor.
My wife Joy and I cooked beans over the fireplace and burned some old clothing to keep the temperature in the apartment above 40 degrees. After our fire died, our complex issued an “Important Message For Residents” warning that Dallas might ration water as treatment plants froze: “Please take action NOW to fill pots/pitchers, bathtubs and other storage containers … use this water to flush toilets.”
Joy, who had recently moved here from Bolivia, had seen her WhatsApp fill up with worried messages from loved ones who’ve watched America’s panoply of recent crises unfold. They asked if she was safe from the horrors on their televisions: the world’s worst Covid-19 numbers, horned defectors with assault weapons, and now infrastructure that abandons people during natural disasters.
After reading the hoard-water note, she turned to me and joked, “I thought the United States was a first-world country?”
In her eyes, a developed country and its state leaders should take care of its citizens. Millions of Texans have seen their electricity cut out for hours and days at a time in a deadly rolling crisis that began with snowfall on Valentine’s Day. Though most power is now restored, millions of Texans are still without water as treatment plants recover. The crisis has been a burden, not just for the state or the power company at fault, but for its residents to bear.
You see, we’re individuals, and, like one Texas mayor wrote on Facebook, we shouldn’t expect state institutions to help. “No one owes you or your family anything; nor is it the local government’s responsibility to support you during trying times like this! Sink or swim, it’s your choice!” then-Mayor Tim Boyd of Colorado City, a town of fewer than 5,000 people a four-hour drive west of Dallas, told constituents in a typo-laden Facebook post. (That same day, he announced his resignation, but he didn’t say whether his exit stemmed from the backlash.)
We were on our own.
We lost power for most of Monday and Tuesday, but luckily, we never lost water. Many Texans fared worse. Houston firefighters had to deal with low water pressure when dousing residential fires started by candles, displacing dozens of Houstonians. Prison inmates had to live with overflowing, unusable toilets for days. Exotic animals, including a chimpanzee and other primates, froze to death in a San Antonio rescue. By last Tuesday, hospitals had treated more than 50 people for carbon monoxide poisoning; desperate to get warm, they’d heated their homes with gas stoves and running cars. A woman near Houston filed a wrongful death lawsuit against power utilities after her 11-year-old son froze to death in his bed.
The disaster worsened existing crises in average Texans’ lives. My neighbor, a nurse who underwent several major surgeries this year amid the pandemic, began to seem less social and more withdrawn. My boss’s mother suffered a stroke just before the storm, and his energies were split between caring for her and making sure his water pipes didn’t freeze. I was depressed and disagreeable.
I draw a line from this catastrophe to America’s fetishized individualism for which Texas, home to a fierce secessionist movement, is the poster child. Texas is where the West starts, home of high-riding cowboys and oilmen who project an image of self-reliance — all they needed to prosper was a government that stayed out of their way.
I work for a manufacturer that makes devices for the power industry, and I can’t conjure a better example of the Texas government’s light touch than its relationship to the electric grid. As electricity infrastructure evolved in the 1930s, the federal government regulated energy across state lines. But Texas had its own grid network, the Texas Interconnected System, and a flourishing oil trade. So the state shrewdly spurned interstate grids.
In the 1970s, the Electric Reliability Council of Texas, or ERCOT, was formed to manage the state’s electricity distribution. But in 2002, Texas deregulated its energy market, creating an environment in which electricity retailers compete for business. The lowest bidder would win customers in the marketplace, but that encouraged power generators to delay or neglect weatherizing critical equipment. In 2011, the Federal Energy Regulatory Commission warned ERCOT that power plants must winterize their equipment. Electricity providers, beholden only to the market, largely ignored the advice.
Put simply, this market created a larger disaster when the freezing weather hit. Because the function of the Texas power industry is to provide cheap electricity, it has no incentive to make costly preparations to its infrastructure for comparatively rare cold weather.
As Uri intensified, enough people were using electric heaters and enough generation equipment had frozen that demand outpaced supply, and the grid’s frequency began to destabilize. Officials told the Texas Tribune Thursday the grid was “minutes” from a full crash, which would’ve taken weeks to restore. ERCOT then mandated statewide “rolling blackouts” to reconcile the grid’s burden with power generation.
It initially said the outages would last less than 45 minutes, but when I woke up that morning, the lights and heat were out. I spent an hour on a dying cellphone navigating overwhelmed service hotlines for any nugget pointing to restored power. I learned the outage could, in fact, last hours, and I gave up calling. Local officials gave suggestions on how to make do. The city of Fort Worth told constituents to close their blinds and stuff towels in cracks to retain heat.
This disaster doesn’t appear to have inspired sober reflection among many of our politicians. On Fox News last week, Republican Gov. Greg Abbott blamed wind turbines for the crisis; in fact, natural gas equipment is responsible for the bulk of the losses. Cranking up the invective, Abbott fingered as a culprit the Green New Deal, a policy framework to address climate change that Congress rejected in 2019. And, of course, our climate-change-denying Republican Sen. Ted Cruz famously jetted off from Houston to Cancun with his family mid-crisis as Texans froze to death.
Individualist thinking justifies this mentality. It says that states and individuals should marshal and deploy their own resources, a notion as American as apple pie. If you lack the resources to get to a Mexican beach resort, hike your sleeves, chop firewood, and don’t burn down your home.
I ended up chopping wood. I’m lucky that I had the option to — it allowed us to stay warm for part of Tuesday morning, and it was better than huddling in a darkened bedroom. But not everyone lives in a forested apartment complex, and others were forced to turn to potentially deadly methods, like a grandmother who spent a night in her car to keep warm.
The fact that I even had a survival hatchet feels ironic. I’m mostly skeptical of prepper culture, partly because it reeks of that individualism. Yet Joy and I frantically built our emergency bags in January after Trump supporters attacked the US Capitol. A friend who works in logistics told me corporations were preparing for a doomsday scenario after the DC raid — cutting emergency credit cards for employees, making extraction plans. Our form of government forces us to prep, and when you’re on your own, it pays to have the tools.
Still, during Uri, ordinary Texans didn’t just help themselves. They distributed food, donated and organized mutual aid funds, and, if they had electricity, took shivering strangers into their homes. A coworker ran errands for neighbors who can’t drive in snow. An acquaintance brought an elderly woman coolers full of water so she could flush the loo.
Tuesday night, our neighbor knocked on our door with an Ikea tote full of more black willow. “They cut this firewood, you want some?”
It was sweet to be cared for by our community. But it’d be better if our government looked after us instead.
Aaron Hedge is a Dallas-based writer and a reader at Longform.org.
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A panel of expert advisers to the Food and Drug Administration (FDA) voted unanimously on Friday afternoon to recommend the one-dose Covid-19 vaccine developed by Johnson & Johnson for an emergency use authorization. The next step is for the FDA to accept the recommendation, which could happen as soon as this weekend, clearing the way for distribution.
Earlier this week, the FDA posted a briefing going over the results of the phase 3 clinical trials of the Johnson & Johnson vaccine, which included 40,000 participants in several countries divided randomly into placebo and treatment groups.
The most important finding: The vaccine was 100 percent effective after 28 days at preventing deaths and hospitalizations from Covid-19 among the clinical trial participants who received the treatment. (Two vaccine recipients were hospitalized with Covid-19 two weeks after receiving the injection.)
The vaccine was also 66.1 percent effective at preventing symptomatic Covid-19 illness after four weeks, with consistent results across all age groups. When looking at blocking severe and critical cases of Covid-19, the Johnson & Johnson vaccine was 85.4 percent effective.
Mathai Mammen, global head of research and development for Janssen Pharmaceutical Companies, said during a press conference last month that the vaccine also had “plain vanilla safety results,” with the vast majority of recipients experiencing no problems. Most of the reported symptoms were mild, including fatigue, arm pain, and fever.
The efficacy levels against severe to critical Covid-19 changed depending on where the vaccine was tested. It was 85.9 percent in the United States after four weeks, while in South Africa, where a coronavirus variant with worrisome mutations that help it escape vaccines has been spreading widely, efficacy against severe disease was reduced to 81.7 percent.
Health officials say that while the Johnson & Johnson efficacy results are not as high as those from Moderna and Pfizer/BioNTech, the two vaccines that have already received emergency use authorizations from the FDA, the new vaccine’s performance is still superb.
“If this had occurred in the absence of a prior announcement and implementation of a 94, 95 percent efficacy [vaccine], one would have said this is an absolutely spectacular result,” said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, during the press conference last month. The vaccine was developed by Janssen Pharmaceuticals, a division of Johnson & Johnson based in Belgium, together with Boston’s Beth Israel Deaconess Medical Center.
But unlike the vaccines from Moderna and Pfizer/BioNTech, Johnson & Johnson’s doesn’t require a booster shot, circumventing the two-dose problems posed by its competitors. There’s no need to track people down for their second dose, which means more people could be vaccinated faster. The shots also don’t require deep-cold storage, which means they’re less costly and somewhat easier to distribute.
“It’s a complete game changer,” said Georgetown University health law professor Lawrence Gostin. “It completely changes the equation.”
The Johnson & Johnson vaccine is also different in another way. It uses an adenovirus vector to deliver instructions for making the spike protein of the coronavirus, which is also less expensive to manufacture than the mRNA platform used for the other vaccines. (It’s estimated to cost around $10 per vaccine dose — roughly half the cost of the Pfizer/BioNTech vaccine.)
Johnson & Johnson has promised enough vaccines for 20 million Americans by the end of March and 100 million Americans by the end of June despite production challenges. It would be a huge boost to the 65 million Covid-19 vaccine doses that have been administered in the US so far.
So even with an overall efficacy level that’s lower than the two other vaccines on the US market, the Johnson & Johnson vaccine could become a major player. It’s the vaccine that “can increase equity,” said Saad Omer, the director of the Yale Institute for Global Health, particularly “if it’s deployed strategically in nations that are hard to reach and where that would be a particular challenge under a two-dose schedule.” Johnson & Johnson expects to distribute a billion doses of its vaccine worldwide this year.
But as amazing as it is to see several effective Covid-19 vaccines developed in record time, it’s now clear that the technology alone won’t save the day. An orchestra of supply chains, manufacturing, logistics, staff, and public trust needs to harmonize in order to actually get billions of shots into arms around the world and finally draw the pandemic to a close. And we also have other hurdles to overcome: controlling the spread of variants that seem to be threatening the effectiveness of all the vaccines we have.
What we learned about the safety and efficacy of the Johnson & Johnson Covid-19 vaccine
Johnson & Johnson launched separate clinical trials testing both a one-dose and a two-dose regimen to see how well these strategies provided long-term protection against Covid-19. The one-dose phase 3 trial arm yielded efficacy results first.
But hints that this vaccine could be safe and effective have been trickling out for months. The company published some of its early phase 1 and phase 2 trial data in a preprint paper in September, and the final version of the paper in January, in the New England Journal of Medicine. The papers showed the vaccine was well tolerated among the participants, and seemingly very effective: With one dose, after 29 days, the vaccine ensured that 90 percent of participants had enough antibodies required to neutralize the virus. After 57 days, that number reached 100 percent.
“When I looked at that, I thought, wow, this Johnson & Johnson product is very powerful after the first dose in terms of immunogenicity,” said Monica Gandhi, a professor of global medicine at the University of California San Francisco. “The Pfizer and Moderna vaccines needed two doses to get that level of [virus] neutralization.”
Like Pfizer/BioNTech, Johnson & Johnson “didn’t rush to phase 3 [trials],” said Hilda Bastian, a scientist who has been tracking the global vaccine race. Instead, it tested multiple vaccine doses and candidates at the outset to figure out which might perform the best in humans, and then proceeded through clinical trials.
The vaccine was also tested in nine countries — the largest single international phase 3 trial in the world, with more than 60,000 participants — meaning many ethnic groups were represented in the data, Bastian said. “As if all that’s not enough, it’s one of the ones that could be manufactured in South Africa and other places,” since Johnson & Johnson has manufacturing capacity around the world, even in countries hard-hit by the pandemic that have been waiting for vaccine supplies, she added.
The day this vaccine gets approval “is going to be a big day for the future of this pandemic [and] a ticket out of this disease for a larger part of the world,” said Nicholas Lusiani, a senior adviser at Oxfam America.
How adenovirus vector vaccines work
Part of the appeal of this vaccine lies in the technology behind it. Adenoviruses are a family of viruses that can cause a range of illnesses in humans, including the common cold. They’re very efficient at getting their DNA into a cell’s nucleus. Scientists reasoned that if they could snip out the right sections of an adenovirus’s genome and insert another piece of DNA code (in this case, for a fragment of the new coronavirus), they could have a powerful system to deliver instructions to cells.
For decades, scientists have experimented with adenovirus vectors as a platform for gene therapy and to treat certain cancers, using the virus to modify or replace genes in host cells. More recently, researchers have found success using adenoviruses as vaccines. Already, an adenovirus vector vaccine has been developed for the Ebola virus.
In addition to Johnson & Johnson and AstraZeneca/Oxford, CanSino Biologics of China is also developing an adenovirus vector Covid-19 vaccine; Russia’s Sputnik V Covid-19 vaccine uses this platform, too.
To make one of these vaccines, the adenovirus is modified so that it can’t reproduce but can carry the instructions for making a component of a virus. In the case of Covid-19, most adenovirus vector vaccines code for the spike protein of SARS-CoV-2, the part the virus uses to begin an infection.
Human cells then read those instructions delivered by the adenovirus and begin manufacturing the spike protein. The immune system recognizes the spike proteins as a threat and begins to build up its defenses.
Since adenoviruses exist naturally, they tend to be more temperature-stable than the synthetic lipid nanoparticles that are used to deliver the mRNA in the Moderna and Pfizer/BioNTech vaccines.
“The nice thing about the adenovirus vector vaccines is that they’re a little more tolerant to a longer shelf life, to the conditions of storage,” said Angela Rasmussen, a virologist at Georgetown University. Adenovirus vector vaccines can be stored at refrigerator temperatures, while mRNA vaccines need freezers, with Pfizer/BioNTech’s vaccine requiring temperatures of minus 80 degrees Celsius.
This helps lower the cost and complexity of manufacturing, distribution, and administration of adenovirus vector vaccines compared to other platforms. And simply having another vaccine on the market, made by a major pharmaceutical company with its own manufacturing infrastructure, is a big step forward. “The more vaccine doses we can have, the better,” Rasmussen said.
What comes next
The next challenge for Johnson & Johnson, after getting a green light from the FDA, is actually delivering doses to millions of arms.
But with three vaccines eventually on the market, should people hold out for any one vaccine in particular?
“Right now when people ask me, which, you know, which vaccine should I get? It’s pretty easy to answer that question because it’s whichever one you get offered,” said Paul Sax, a professor of medicine at Harvard Medical School. Vaccine supplies are limited, the transmission of the virus is high, and hospitals are close to capacity, so few people can be picky about what they get.
On the other hand, once vaccine supplies stabilize, having multiple vaccines with different characteristics could allow doctors and public health officials to optimize how the shots are distributed. “If the efficacy [of a given vaccine] is lower but still pretty good, there may be a scenario that one vaccine is recommended for low-risk populations and another one is for a high-risk population,” Omer said.
Though the Johnson & Johnson vaccine does have some key advantages over its competitors, it could face some of the same distribution snags that have hit other vaccines, like miscommunication between the government and hospitals, and production hurdles.
Researchers say that all the manufacturers also need to start working to get vaccines to the rest of the world. The new variants that have emerged in the UK, Brazil, and South Africa and have been detected in other parts of the world are reminders that the virus continues to evolve, and that a partially vaccinated population could exert more selection pressures that accelerate these mutations. So vaccination has to happen fast, and globally — and Johnson & Johnson’s vaccine may be a critical tool to do this.
“Long term, we need to be thinking about getting vaccines out equitably to the entire world, and having vaccines that are easier to distribute in terms of the cold chain requirements is going to be huge in that regard,” Rasmussen said.
But even as these vaccines roll out, there’s still more to learn: how long protection from vaccines last, whether there are any rare complications to consider, whether they prevent transmission as well as disease, and how well these vaccines work against the new variants. There are already some troubling signs of how these variants might eventually be able to evade vaccines. Continuing clinical trials will be critical, Sax said.
“You know, we’ve got millions of people who’ve received these vaccines already, which is exciting,” he added. “We’re on our way.”
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The Senate on Wednesday took an important step forward on limiting emissions — and meeting its commitments to curb global warming — by voting to limit the unbridled release of methane molecules, often a byproduct of natural gas production, into the atmosphere.
The 52-42 vote reinstates the Oil and Natural Gas New Source Performance Standards, a handful of Obama-era regulations on methane emissions rolled back by former President Donald Trump in August 2020. The measure drew support from every Senate Democrat, as well as Republican Sens. Susan Collins (R-ME), who has opposed GOP efforts to deregulate methane emissions in the past; Lindsey Graham (R-SC); and Rob Portman (R-OH). The rule is expected to be taken up and passed by the House of Representatives in May.
The standards alone won’t be sufficient to meet President Joe Biden’s pledge to slash greenhouse gas emissions by 50 to 52 percent compared with 2005 levels by 2030 — a goal meant to help keep global warming this century to 1.5 degrees Celsius — but it represents an important step toward meeting that commitment, given that methane is increasingly seen as a driver of climate change. The vote did not receive the support of 10 Republicans — the number Democrats need, barring any changes to the filibuster, to pass more sweeping climate legislation — but the fact three GOP senators signed on suggests Democrats have at least some hope of winning over Republicans on at least some climate-related issues.
This rule change required only 51 “yes” votes, as Democrats took advantage of the Congressional Review Act, which allows legislators to undo laws passed by previous administrations in their lame-duck periods with a simple majority in each chamber of Congress. It’s filibuster-proof. Trump’s methane regulation, adopted by the EPA last summer, is the first rule for which Democrats are using the legislative procedure, which Republicans used 14 times in the first 16 weeks of Trump’s presidency four years ago.
When it comes to oil and natural gas pipelines, methane leaks are disconcertingly common and a major contributor to the methane currently in the atmosphere. Obama’s regulations, passed in 2016, were meant to change that; they required energy companies to monitor pipelines for leaks and plug any they found. Bringing those regulations back is “absolutely common sense,” Sen. Martin Heinrich (D-NM), a member of the Senate Energy and Natural Resources Committee and a cosponsor of the resolution, said at a Tuesday press conference.
Notably, some energy companies, including BP, Shell, and Exxon, are on record as being on board with increased methane regulation. Heinrich said that’s because complying with its rules would actually save money: Pristine pipes and plugged-up leaks lead to higher yields and greater profits, enough that the costs of securing infrastructure are offset.
And Dan Zimmerle, a senior research associate in the Energy Institute at Colorado State University, said companies also appreciate methane regulations because they lead to increased accountability, making methane — a major component of natural gas, which is often promoted as an alternative to coal — seem safer to consume than it actually is.
“The largest threat to natural gas is not the cost of regulation, it’s the reputation of natural gas,” Zimmerle said.
Republicans, with the noted exception of Collins, Graham, and Portman, have thus far opposed any attempts at energy regulation, including this one, arguing that there are other, less regulatory and more business-friendly ways to take care of the climate. But Democrats argue that regulation of greenhouse gases is critical — and that without it, the United States will fail to ward off the dangers of climate change.
Why reducing methane emissions is critical, briefly explained
Senate Majority Leader Chuck Schumer cast the Senate’s move as “one of the most important votes, not only that this Congress has cast but has been cast in the last decade, in terms of our fight against global warming.”
In a lot of ways, Schumer is right.
Greenhouse gases work by inhibiting the free movement of the sun’s rays that heat the Earth. Gasses such as carbon dioxide and methane absorb the radiation that comes up from the Earth’s surface toward space, trapping it. If emissions continue to increase at the current rate, the atmosphere could warm by 3 to 4 degrees Celsius by the end of the century. The results could be catastrophic.
The problem with methane is that it traps heat incredibly effectively — about 25 times more effectively than carbon dioxide, according to the EPA. While it accounts for only about 16 percent of the world’s greenhouse gas emissions, the manner in which it traps heat means any significant reduction would likely have a positive impact on climate change.
Limiting emissions, as the rules change would, helps address the fact that methane’s presence in the atmosphere is increasing exponentially as a byproduct of human activities such as farming and energy production. In fact, even as the world locked down amid the Covid-19 pandemic, carbon dioxide and methane emissions hit record highs. And it’s possible they could rise further as countries begin to reopen.
All that makes methane reduction key to keeping global warming as low as possible. A 2021 report in Environmental Research Letters found that concerted efforts to reduce man-made methane emissions could decrease global warming by as much as 30 percent.
More methane regulation is needed
Given the current severity of methane emissions, many scientists worry the Obama-era regulations will never be enough to tangibly curb methane emissions.
Robert Howarth, a professor of ecology and environmental biology at Cornell University, was one of the scientists invited to give a briefing on methane emissions to senior White House staff in May 2016, just before the regulations were drawn up. Howarth said one issue with the Obama rules is that they’re missing mechanisms to verify that energy companies are complying with the regulations.
“Methane is a colorless, odorless gas; you can’t see it with the naked eye,” Howarth said. “A layperson can’t see — I can’t see — if the facility is leaking or not. If you don’t have an independent means by skilled people who are verifying what the emissions are, then you’re simply relying on industry to say ‘we’re taking care of it.’ That doesn’t work for me.”
Howarth argued it’s a loophole that can be closed with today’s technology. Microsatellites tuned to measure methane, managed and owned by global governments and private companies, can look for unchecked and unplugged methane emissions. That technology didn’t exist four years ago.
Zimmerle, the Colorado researcher, called the development promising but said that “there are other places, like gas schematics or a whole variety of other specific sources, where everybody knows the emissions are larger, but for whatever reason, they’re not the point of attention.”
There have been other, similar critiques about the limits of the Obama-era rules. For instance, some experts have noted the rules apply only to new extraction sites, leaving older, leaky sites to continue operating.
As senior Vox reporter Rebecca Leber has written, the Biden administration has acknowledged that just bringing back old regulations that don’t go far enough won’t suffice. Exactly how it plans to address the loopholes and reach its target is unclear, but the White House has promised to release details by September. In the meantime, however, the rules change represents a small step forward — and a little less methane in the air.
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The Covid-19 pandemic now appears to be the worst it has ever been, with daily new cases worldwide topping 800,000 several times over the past week. More new cases have been reported in the past two weeks than in the first six months of the crisis.
More than one in three of these new cases were reported in India, the world’s second-most-populous country and now the epicenter of Covid-19. The rising infections, deaths, and strained health system have created a humanitarian crisis, one that may not relent for months.
Other parts of the world that have barely begun to vaccinate people may soon see their own surges in Covid-19.
What’s complicating the situation is the rise of new variants of SARS-CoV-2, the virus that causes Covid-19. Several of these variants contain mutations that can make prior immunity less effective, allow the virus to spread more readily, and, in some cases, cause more deaths. And the more the disease spreads, the more variants can arise.
The SARS-CoV-2 variant first identified in India last year, called B.1.617, has already become the dominant version of the virus in some parts of the country and could be a driver, among others, of the current outbreak. And it’s one reason countries are now imposing travel restrictions on flights from India. Other variants have already arisen independently in different parts of the world and have rapidly gained ground, too. The World Health Organization (WHO) is now tracking 10 SARS-CoV-2 variants internationally.
It may be hard to grasp the current scale of the pandemic from the US, which has so far managed to fully vaccinate at least one-third of its population while seeing precipitous drops in new cases, hospitalizations, and deaths. All three of the vaccines that have begun distribution in the US have proven to be highly effective at preventing hospitalizations and deaths from Covid-19, the worst consequences of the disease.
However, the US can’t afford to be complacent. Several of these more dangerous variants have already arrived in the US. The Centers for Disease Control and Prevention (CDC) released new Covid-19 models and found that variants are poised to drive an increase in new cases in May.
The challenge now is to vaccinate people to contain the spread of the virus, not just in the US but around the world. As long as the virus is spreading anywhere, it can mutate in threatening ways. But variants aren’t the only factor at play; public health measures and political will to contain the disease will also shape the remainder of the pandemic. How these factors are converging can be confusing, so here are nine questions and answers that may clarify some of the concerns:
1) What is a variant?
Viruses mutate all the time, making mistakes in copying their genetic code as they replicate. Most of these mistakes are actually detrimental to the virus or have no effect. But in rare cases, a change in the genetic code can occur that confers an advantage to the pathogen, alters how it functions, or makes it harder to counter.
The term “variant” refers to a virus strain with a distinct grouping of mutations. Sometimes these variants contain dozens of individual mutations compared to the original strain of a virus. The combination of mutations in these variants may even be working together, making the variants more dangerous than versions of the virus with individual mutations.
Variants of SARS-CoV-2 have arisen at several points during the pandemic, but what’s concerning about the variants spreading right now is that they seem to be better able to spread. Some also seem to lead to more severe outcomes from Covid-19. And several variants seem to be better able to evade the immune system in people who were already infected or in people who have been vaccinated. So variants can increase the chances of a Covid-19 survivor getting reinfected or raise the likelihood of a breakthrough infection in someone who received a vaccine.
2) Why did variants show up all of a sudden?
There are several factors behind why so many SARS-CoV-2 variants have emerged. One is simply that the virus has been spreading to more people in more countries. With more infections, there are more mutations, thereby creating a greater likelihood of a rare combination of those mutations converging in a way that poses a threat.
Selection pressure is playing a role, too. As more people gain immunity through infection or vaccination, the variants that can evade that immunity remain and can circulate.
“It is not an accident that these variants first arose in areas that have a record of poor implementation of measures to mitigate spread and very high rate of infection,” said Theodora Hatziioannou, a research associate professor of retrovirology at the Rockefeller University, in an email. Places like the United Kingdom, for instance, saw major spikes in Covid-19 earlier in the pandemic and struggled to impose lockdowns, creating plenty of opportunities for mutations and the eventual B.1.1.7 variant that was first detected there.
Another factor is that many parts of the world are doing more genetic surveillance of Covid-19. Rather than just detecting the presence of the virus, this work involves sequencing the genome of the virus. It can reveal which specific variant is in circulation in a given area and can detect new mutations as they arise. But in many parts of the world, surveillance is inadequate or nonexistent, which means other variants could be spreading undetected.
3) Which Covid-19 variants are the most concerning?
SARS-CoV-2 variants are grouped into three categories. A variant of interest is one that contains mutations known to affect how the SARS-CoV-2 virus binds to human cells. It could lower the efficacy of Covid-19 treatments or render prior immunity less potent. A variant of concern is one that has shown evidence of causing more severe disease or greater transmissibility, or leads to a significant reduction in protection against Covid-19 stemming from prior infections or vaccination. And if existing Covid-19 countermeasures like testing or vaccines are significantly weaker against a variant, it is labeled a variant of high consequence.
The WHO reported on May 3 that it now has seven variants of interest and three variants of concern on its radar.
The variants all have clunky names, and scientists generally try to avoid identifying them based on where they were first detected, though this often happens anyway. The WHO discourages identifying diseases and variants by location because it can be stigmatizing as well as misleading since where a disease is first detected isn’t necessarily where it originated.
One of the main variants of concern for the WHO is known as B.1.1.7. It was first detected in the United Kingdom last year and has since spread around the world and is poised to become the dominant variant in the US. It appears to be more transmissible, hence its rapid spread, and it appears to lead to more hospitalizations and fatalities, hence the concern.
The B.1.351 variant, first identified in South Africa, also seems to be more transmissible. Similarly, the P.1 variant that was initially reported in Brazil is likely to spread more readily among people. Covid-19 treatments like monoclonal antibodies also seem to be less effective against it.
The CDC has its own variant list focused on the US and includes B.1.427 and B.1.429, both first found in California, on its concern list.
But places like the US and Israel are seeing declines in the rate of new Covid-19 cases, hospitalizations, and deaths despite the presence of variants. That’s due in large to part their success in administering Covid-19 vaccines, though factors like warmer weather may also be reducing opportunities for transmission at the moment. It shows that even if a variant is more transmissible, it can be contained with widespread immunization and good public health practices.
4) How do Covid-19 variants work? What makes them so dangerous?
What ties these variants together is that they contain mutations in SARS-CoV-2’s spike protein, the part of the virus that allows it to infect human cells. Several variants actually have some mutations in common, particularly in the receptor-binding domain of the spike protein. The receptor-binding domain comes into direct contact with human cells and commences the infection process. The mutations in this region seem to enhance the affinity of the virus for human cells, which may allow it to reproduce more.
One of the most concerning mutations in this region is known as E484K, where the amino acid glutamate is replaced by the amino acid lysine at position 484 in the spike protein. It has been found in several variants, including B.1.525, P.1, B.1.351, and some strains of B.1.1.7. It is also known to be an escape mutation because it can help the virus evade the immune system’s defenses. That means variants with this mutation might be more likely to reinfect people who have already had Covid-19.
Similarly, the N501Y mutation in the receptor binding domain has also been identified in variants like P.1, B.1.1.7, and B.1.351. It too enhances transmission.
There are also mutations outside of the receptor binding domain that can change the overall shape of the spike protein in a way that makes it more efficient at invading cells or make it a tougher target for the immune system.
However, scientists are still working to confirm exactly how these variants function and how these mutations may be working in concert.
5) Are Covid-19 variants driving the devastation in India?
The number of daily new infections in India has not dipped below 300,000 over the past two weeks, and that is likely an undercount given the difficulties of testing for the virus and limited access to health care for many Indians. Some estimates show the actual case counts could be 10 times higher. The cases are driving shortages of hospital space, personnel, protective equipment, oxygen, and even crematorium capacity. Yet the Indian government remains reluctant to impose new restrictions on movement and public gatherings.
One of the factors at play is a SARS-CoV-2 variant known as B.1.617 that was first identified in India in October 2020 and has since been found in at least 17 countries, including the US. It’s been described as a “double mutant,” which isn’t technically accurate because it contains many different mutations. But it does contain two mutations that have been observed in other strains to increase transmissibility and evade some of the immune protection some people have from previous Covid-19 infections.
B.1.617 has already become the dominant variant in several Indian states. The situation echoes the P.1 variant outbreak in Brazil. In January, that variant spread rapidly in the city of Manaus, which had already faced a major Covid-19 outbreak in October 2020 that led to more than three-quarters of the population getting infected, according to some estimates.
The cause of Brazil’s second wave isn’t certain, but it may have been due to a combination of immunity waning from the first wave coupled with a variant that’s more transmissible, allowing for reinfections.
A similar situation may be occurring in India with the B.1.617 variant, but the evidence isn’t clear yet that it’s the main culprit behind the massive surge in infections. India is also coping with the B.1.1.7 and B.1.351 variants.
And both Brazil and India have made critical missteps in their public health responses to Covid-19. Brazilian President Jair Bolsonaro routinely dismissed the severity of Covid-19 and is now facing an investigation from Brazil’s Senate over his mishandling of the pandemic.
Indian Prime Minister Narendra Modi’s political party declared that the country had “defeated” Covid-19 back in February. Restrictions on public gatherings were lifted, major religious festivals took place, and political rallies continued. “I think that there was complacency here,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.
And although India is the world’s largest vaccine manufacturer, Covid-19 vaccination rates in its population remain low, leaving hundreds of millions vulnerable to infection. More than 150 million shots have already been administered in India, but some analysts warn vaccinating all eligible adults in the country could take years. The main vaccines being administered are the University of Oxford/AstraZeneca vaccine, known in India as Covishield, and the Covaxin vaccine made by Indian pharmaceutical firm Bharat Biotech. Russia’s Sputnik V vaccine was also recently approved in India, with injections arriving last week. All of these are two-dose vaccines and seem to retain protection against the variants circulating in India.
It may be that the combination of the more transmissible B.1.617 variant, relaxing restrictions too soon, and a low vaccination rate are all fueling the Covid-19 devastation in India. This surge in cases has global implications since India’s vaccine production is critical to vaccinating other countries.
If the virus continues to spread unchecked, it will increase the chances of another dangerous variant emerging. And other countries that have similarly low vaccination rates and poor public health responses could experience major increases in cases in the coming months.
6) Do Covid-19 treatments still work against the variants?
There are a variety of treatments now available for Covid-19 that have helped reduce the severity and lethality of the disease.
However, some of the more targeted treatments, like monoclonal antibodies, seem to be less effective against several of the Covid-19 variants, like B.1.351 and P.1.
Antibodies are proteins produced by the immune system that can attach directly to a specific part of the virus, inhibiting its function or marking it as a target for white blood cells to eliminate. Monoclonal antibody therapies — like the ones from Regeneron and Eli Lilly — harness and clone a single antibody that is known to be highly effective at binding to its target (Regeneron’s drug uses a cocktail of two monoclonal antibodies).
In the case of Covid-19, the target for these drugs is the spike protein of the virus. But if the spike protein mutates in the spot that the antibodies target, then these drugs could become less effective. In April, the Food and Drug Administration (FDA) revoked its emergency use authorization for the monoclonal antibody therapy developed by Eli Lilly when used alone because several of the new Covid-19 variants seem to be resistant to it. Combinations of two or more antibodies still appear to be effective, possibly because the antibodies target different parts of the spike protein and it’s less likely for both locations to have mutations.
On the other hand, more general treatments for Covid-19 are not likely to be affected by the variants. Corticosteroids like dexamethasone tamp down on the immune system’s overreaction to the virus rather than targeting the virus itself, so mutations likely won’t have a major impact. Remdesivir, an antiviral drug and the only one with full FDA approval to treat Covid-19, seems to be just as effective against the new variants as it is against the original strain, but there remain questions about how effective the drug was to begin with.
7) Will vaccines still protect you against the variants?
For now, the main Covid-19 vaccines being distributed across the US — from Moderna, Johnson & Johnson, and Pfizer/BioNTech — remain highly effective at preventing illness, hospitalizations, and deaths, even from the new variants reported so far.
“It is true that there is less efficacy against these new variants, but it doesn’t mean there is a complete absence of protection,” said Fikadu Tafesse, an assistant professor at Oregon Health & Science University. “The good thing is these vaccines are extremely good.”
One of the main exceptions, however, is the University of Oxford/AstraZeneca vaccine. It failed to hold up well against the B.1.351 variant that’s become predominant in South Africa. It performed so poorly in trials that South Africa decided to halt the use of the vaccine and is now selling its supply to other countries. This vaccine has not yet been approved for use in the US but is still being administered in other countries where B.1.351 is not in widespread circulation.
On the other hand, even the best vaccines are not a perfect defense. Health officials have observed a number of “breakthrough” cases where people still managed to contract Covid-19 after being vaccinated. However, the breakthrough rate is much, much lower among vaccine recipients than the infection rate among unvaccinated people.
And among the breakthrough cases, the illness was much less severe, with most patients reporting mild or no symptoms. This shows that Covid-19 vaccines not only prevent illness but make the illnesses that do occur much less dangerous, downgrading the disease from a life-threatening malady to a minor annoyance for most people.
“We have to change our definition of Covid-19 experience [away] from being infected,” said Larry Luchsinger, vice president and director of research operations at the Lindsley F. Kimball Research Institute at the New York Blood Center. “The conversation has to change back to ‘how severe was your reaction.’”
8) Will we need new vaccines or boosters to protect against variants?
Given that most Covid-19 vaccines remain strong against variants, it’s not clear yet whether we will need booster doses for vaccines or if vaccines will need to be reformulated. For example, a recent study just found that the Pfizer/BioNTech Covid-19 vaccine is still effective against the B.1.1.7 and B.1.351 variants, albeit with reduced efficacy.
That could change as more variants arise or if it turns out that immunity to Covid-19 declines faster than the rate of the virus in circulation. And the approach may be different depending on whether someone received a vaccine or gained immunity from a prior infection.
“Recent evidence suggests that, at least for people that had been previously naturally infected, vaccination confers a high level of neutralizing antibodies that can neutralize even the variants of concern,” Hatziioannou said. “This to me suggests that repeated exposure to the antigen could be potentially advantageous and I would be in favor of booster shots.”
Part of the challenge is that Covid-19 has only been around for just over a year, so scientists don’t have a good handle on how long immunity will last from a vaccine or from a previous infection. Experiences with past coronaviruses do show that immunity can last for several years. If the Covid-19 pandemic is sufficiently controlled before immunity fades, boosters may not be necessary.
An advantage of several of the Covid-19 vaccines is that they can be easily and quickly modified. The Moderna vaccine and the Pfizer/BioNTech vaccine are based on a molecule called mRNA. It carries instructions for making the spike protein of SARS-CoV-2. The Johnson & Johnson vaccine and the Oxford/AstraZeneca vaccine use a modified adenovirus to carry DNA that codes for the SARS-CoV-2 spike protein.
Human cells read that DNA or mRNA genetic information and make the spike protein. The immune system then detects the spike protein and starts to mount a response. To modify these vaccines, one only needs to alter the genetic instructions, which can be done within days.
Vaccine manufacturers are currently studying booster doses — an extra dose of the same vaccine — as well as reformulated vaccines to target specific variants. Moderna, for instance, has already reported early results that show its modified vaccine neutralizes the P.1 and B.1.351 variants. For its part, the FDA has also cleared the way to deploy new formulations of Covid-19 vaccines so that they don’t have to go through the same tedious and expensive clinical trials process to get approval. Instead, the modified vaccines will go through a more condensed testing regimen akin to annual influenza vaccines, allowing them to be deployed faster.
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9) Will variants thwart our attempts to return to normal?
Only if we let them.
Vaccination remains the most powerful way to corral Covid-19, but it’s only one component in a suite of public health tactics. Until the vast majority of people are immune, wearing face masks, proper ventilation, and social distancing will also be needed, depending on the specific situation. Genetic surveillance is also critical to staying ahead of the variants.
The goal is to get enough of the population immune to Covid-19 such that the virus can’t spread easily. That threshold is known as herd immunity, and for Covid-19, it may take between 70 and 80 percent of the population to become immune. And vaccination helps ensure that if cases do occur, they remain mild and there is adequate capacity in the health system to deal with them.
However, herd immunity isn’t a fixed line. It can change depending on the particular variant in circulation and the susceptibility of the population. And it can change from place to place depending on the level of immunity in a given region.
Right now, the US is shifting away from vaccinating the willing to vaccinating those that may be more reluctant. Immunizing those holdouts may end up being the critical factor in drawing down the pandemic. But if they remain vulnerable, that could allow the virus to continue to circulate and spawn new outbreaks.
The biggest threat, though, remains the ongoing and unchecked spread of Covid-19 across many parts of the world. These cases are not just an enormous human tragedy but the surge in infections threatens to undermine precious gains against the disease.
And the current pace of vaccination is alarmingly low. Estimates show that it will take until 2023 to vaccinate some countries against Covid-19. If the pandemic drags on that long, the whole world will remain at risk. As economies reopen and international travel picks back up, controlling the spread of Covid-19 in other countries will become even more important as the chances of another variant spreading will increase. That’s why ending the crisis as we know it demands a global lens, with a coordinated international effort to vaccinate the world and to reach the most vulnerable.
The Biden administration has announced that it will work with the World Trade Organization (WTO) to negotiate a deal to suspend intellectual property rights associated with the Covid-19 vaccines — a surprise move for the administration, which had initially resisted taking such a step.
The reversal came as Covid-19 deaths are mounting in India and elsewhere. The vaccination program in the US is going well, but much of the world is still waiting for vaccines, which has made the role of pharmaceutical companies and intellectual property in the global vaccine effort the subject of intense debate.
There is unanimous agreement on one thing: There is a lot of work to be done to speed up vaccine manufacturing and vaccinate the world. As the WTO’s General Council meets this week, patents have risen to the top of the agenda. India and South Africa have asked the WTO to waive intellectual property (IP) rules relating to the vaccines so that more organizations can make them.
The case for waivers is simple: Waiving IP rights might enable more companies to get into the vaccine-manufacturing business, easing supply shortages and helping with the monumental task of vaccinating the whole world. The case against them: Taking IP rights from vaccine makers punishes them for work that society should eagerly reward and disincentivizes similar future investment. Opponents have also argued this step would do very little to address the vaccine supply problem, which has largely been the result of factors such as raw material shortages and the incredible complexity and tight requirements of the vaccine-manufacturing process.
The debate has raged for the past several weeks — with Bill Gates as a notably outspoken defender of IP rights — but recently intensified as the Covid-19 crisis in low-income countries worsens.
Wednesday’s announcement unambiguously puts the US on record in support of such a waiver, a reversal from its previous position. “The Administration believes strongly in intellectual property protections, but in service of ending this pandemic, supports the waiver of those protections for COVID-19 vaccines,” US trade representative Katherine Tai said in an announcement.
Done correctly, making the IP associated with these vaccines available to the world can be a good first step — the more information-sharing here, the better. But it’s a small thing to do at a time when bigger commitments are needed. Waivers might help, but ending the pandemic worldwide is going to require so much more.
While the Biden administration’s decision is a positive development, but debates over intellectual property can also distract the world from the policy measures that could really end the pandemic: building our vaccine-manufacturing capacity, committing to purchase the doses the rest of the world needs, and working directly with manufacturers to remove every obstacle in their path.
Patents, trade secrets, and what you need to know to make a vaccine
To unpack what the Biden administration’s move means, it’s important to understand the role patents play in vaccine manufacturing.
When a pharmaceutical company makes a drug, it applies for a patent. The patent protects its intellectual property for a fixed amount of time, typically 20 years, after which others can make “generic” versions of the drug, which are generally a lot cheaper.
Simple enough, right?
When it comes to Covid-19 vaccines — and many modern pharmaceutical products — the situation is much more complicated than that.
First, a modern vaccine is often in a web of different intellectual property rights, with the vaccine manufacturer having purchased the rights to some elements of its vaccine from either other pharmaceutical companies or researchers.
The lipids (shells that contain the mRNA molecules) used for mRNA vaccines, for example, are licensed to Pfizer and Moderna, but other companies have the rights to them. Patents held by the vaccine companies are actually a fairly small share of what’s going on in this IP web. It’s better to talk more broadly about all of the intellectual property that goes into a vaccine: licensing deals, copyrights, industrial designs, and laws protecting trade secrets.
The other complication is that, while there are legal barriers to copying the existing vaccines, that’s not what’s really making them impossible for other companies to start manufacturing. Experts I spoke with emphasized that, generally speaking, the world’s entire supply of critical raw materials is already going into vaccines, and there are no factories “sitting idle” waiting for permission to start making them. What’s more, changing a factory’s processes to produce a new kind of vaccine is a difficult, error-prone process — which went wrong, for example, when a plant converted to make Johnson & Johnson vaccines spoiled millions of doses.
Moderna is an instructive example here. The pharmaceutical company made a splashy announcement in the fall that it would not enforce its Covid-19 vaccine patents. Despite that move, there is still no generic Moderna vaccine, and none of the experts I talked to believed one was on the horizon. (It turned out well for Moderna — get the PR bump from the announcement without suffering the financial drawbacks.)
In the long run, though, a world where everything Moderna, Pfizer, Novavax, AstraZeneca, and Johnson & Johnson know about manufacturing their vaccines was freely available online would make vaccines easier for other manufacturers to make. It would also make them cheaper and more accessible to countries that have had trouble getting them.
At a meeting this week, the WTO is considering requests from India and South Africa to waive the patents for the duration of the emergency. Most countries have their own patent laws, but international agreements about how they enforce each other’s patents — and disputes when countries suspect each other of ignoring IP concerns — tend to be mediated by the WTO.
Although the Biden administration’s announcement is a win for the pro-waiver side, the US isn’t the only country that needs to be persuaded for the WTO to agree on a patent waiver. For their part, the EU, the UK, Japan, and Switzerland have expressed opposition. But the US is influential in these debates, and the Biden administration’s about-face may well be decisive.
The case against IP waivers
Many global health researchers, Bill Gates (and the Bill and Melinda Gates Foundation), and some within the Biden administration have vocally opposed waiving IP rights on the Covid-19 vaccines, generally with two arguments.
First, they argue society should want pharma companies to invent vaccines like the ones they did for Covid-19, and waiving rights will make that less likely in the future by making similar projects less appealing targets for investment. Second, they contend that patent waivers will set that precedent without even speeding up vaccine manufacturing.
“For the industry, this would be a terrible, terrible precedent,” Geoffrey Porges, a research analyst at SVB Leerink, an investment bank, told the New York Times. “It would be intensively counterproductive, in the extreme, because what it would say to the industry is: ‘Don’t work on anything that we really care about, because if you do, we’re just going to take it away from you.’”
Perhaps most prominent among those who’ve taken this stance is Bill Gates. “The thing that’s holding things back, in this case, is not intellectual property,” Gates said in a controversial interview on Sky News. “It’s not like there’s some idle vaccine factory with regulatory approval that makes magically safe vaccines. You’ve got to do the trials on these things, and every manufacturing process has to be looked at in a very careful way.”
Instead of intellectual property, Gates’s argument goes, the problem is deep technical know-how: the important details of the process that goes into making a vaccine. This is an especially critical problem for the mRNA vaccines Pfizer and Moderna created because they use a new technique. (The mRNA vaccines give the body instructions it can use to make the spike protein on the coronavirus. From there, the body can recognize it and fight it off. This is different from the vaccines we’re all familiar with, which expose a patient to a dead or weak virus, or a chunk of a virus, to help prime the immune system.)
Moderna and Pfizer know not only the exact formula of their vaccines but also countless procedural details about making them successfully: equipment modification, temperature settings, how to troubleshoot common problems, different kinds of failure and what problems they indicate, and so on. Waiving IP protections won’t make this information available.
This isn’t an instance of Bill Gates going off message; it has consistently been the stance of his foundation. Last year, it worked to convince Oxford to partner with AstraZeneca on vaccine production, a partnership that has come under heavy criticism for having held back the Oxford vaccine’s potential for wider, cheaper sharing as AstraZeneca scaled up production slower than was hoped.
Why would advocates for global health want partnerships with for-profit pharmaceutical companies?
They contend that, if the world predictably waives patents for sufficiently critical medications and vaccines, companies will find it harder to attract investment when they work on those problems. And vaccines developed without a pharmaceutical partner — say, by a university — might have no luck being manufactured at the needed scale. “At our foundation, we believe that IP fundamentally underpins innovation, including the work that has helped create vaccines so quickly,” Mark Suzman, CEO of the Bill and Melinda Gates Foundation, wrote in February.
“From early in the pandemic, there were lots of smart people at the Gates Foundation thinking about how to structure financing and incentives for accelerating vaccine development,” Justin Sandefur, senior fellow at the Center for Global Development, a nonprofit think tank based in London and Washington, DC, told me. “To their credit, they worked on this really early on. They convinced themselves that IP was important.”
(In May, after the Biden administration’s reversal, the Gates Foundation actually reversed course, too, expressing support for a limited waiver.)
Many other global health experts have also made the case that waivers would be a bad idea. Vaccine makers “are already cooperating widely with competitors and generic manufacturers, including via voluntary licenses, contracted production, and proactive technology transfer,” the CGD’s Rachel Silverman argued in a CGD-hosted debate about whether to waive IP. “Diluting that commercial incentive may reduce their interest in pursuing the voluntary horizontal collaborations that are already driving scale.”
The case for IP waivers
The case for IP waivers is that, while there are definitely many other barriers to getting the world vaccinated, removing even one is better than letting it remain in place. As part of a no-holds-barred effort to get the vaccine to everyone, the world should do everything in its power to cut through some of the restrictions delaying vaccines, even if it will take additional steps for this particular action to make a big difference.
“There’s a question of where the onus of proof lies in this situation,” Sandefur told me. “The standard line you hear is, ‘Well, there aren’t that many factories that can do this.’ And I can’t point you to the [specific] factory that’s ready to produce AstraZeneca, but we want to free up the market to let the discovery happen.”
If you really want to get something done, it makes sense to address every possible thing standing in the way of getting it done, even if it’s not the biggest or most significant barrier. And while the vaccines genuinely are incredibly difficult to manufacture, those from Novavax, Johnson & Johnson, and AstraZeneca aren’t quite as out of reach as the mRNA vaccines from Pfizer and Moderna, and years of this fight are still ahead — time during which some company could, perhaps, pull off what has been dismissed as too difficult or even impossible and get generics off the ground a little faster.
What’s implicit in that argument is there’s actually only a small chance of seeing benefits from waivers. But, proponents of waivers argue, there’s also not much chance of harm. If it’s true other companies can’t make the vaccines easily, the IP waivers won’t undercut sales for the existing companies or disincentivize future R&D. Conversely, the only way the IP waivers could actually cut into existing companies’ profits is if they successfully incentivize more vaccine development. If that actually happened, the thinking goes, that’d be worth it.
Some supporters of IP waivers have argued the debate is essentially a matter of class warfare: Gates and Big Pharma against the global poor. But there are passionate defenders of the interests of low-income people on both sides of the IP waiver debate: Many experts who’ve spent their careers fighting for the world’s poor also see IP waivers as a counterproductive step. Smart people disagree on whether this approach does, in fact, increase vaccine access where it’s needed most, and whether it damages our preparedness for the next pandemic.
What the intense focus on IP waivers misses
Regardless of whether they were for or against IP waivers, everyone I spoke to agreed on one thing: IP waivers are much less important than just directly funding poor countries’ access to the vaccine.
Many people who aren’t opposed to IP waivers nonetheless caution against advocating for them because it could distract from better solutions. Silverman called waiver advocacy “an inefficient use of limited global advocacy/political capital for vaccine access.” IP is “not the point in the medium term,” Amanda Glassman, director of global health policy at CGD, tweeted Wednesday.
Her focus: urging governments to give money to Covax so there’s clear demand for increased manufacturing. Covax is supposed to purchase vaccines for the world but has found them scarce; the overwhelming majority of vaccines have been distributed in rich countries. Despite the devastating consequences of letting the pandemic rip through poorer nations, richer countries have been stingy with Covax, and it needs more resources to succeed.
“I think [waiving IP protections] is almost as much of a PR move as anything else,” Derek Lowe, a medicinal chemist who works on drug discovery in the pharmaceutical industry, told me. “There are a lot of people who are convinced that the only thing that’s holding back the generic vaccine is the patents, so the Biden administration said, ‘Okay, let’s see.’”
Indeed, the attention the debate over patent waivers has generated in the past week has obscured an important point: There’s no one trick to making vaccines widely available. Doing so is going to require commitments to buy billions of doses once companies make them, and months of hard work easing the supply bottlenecks that slow down production. Even if companies can manufacture generic versions of vaccines, they won’t do so without committed buyers — and that’s where committing to help poor countries purchase them really becomes essential.
In other words, it would be a mistake to take a victory lap following the Biden administration’s announcement. Even if legal barriers are addressed, countless practical barriers remain between here and vaccinating the world. If the IP waiver is a first step, great. But there are many steps to go if we’re to conquer Covid-19 in every corner of the globe.
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The world may have undercounted Covid-19 deaths by a staggering margin, according to an analysis released Thursday by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington School of Medicine. The actual count may actually be 6.9 million deaths, more than double official tolls.
The United States alone is estimated to have had 905,000 Covid-19 fatalities, vastly more than the 579,000 deaths officially reported, and more than any other country. The calculation is based on modeling of excess mortality that has occurred during the pandemic.
The drastic difference highlights how difficult it is to keep track of even basic metrics like deaths when a deadly disease is raging. The higher toll also means the ripples of the pandemic have spread wider than realized, particularly for health workers on the front lines who have repeatedly faced the onslaught with limited medical resources and personal protection. And the undercounts have important consequences for how countries allocate resources, anticipate future hot spots, and address health inequities.
Researchers who weren’t involved with the analysis say it confirms what many already presumed: that official death counts were far, far off.
“Big picture, it’s not really surprising,” said Jennifer Nuzzo, an epidemiologist and a senior scholar at the Johns Hopkins Center for Health Security. “We’ve long suspected that the tolls of Covid are undercounted for a number of reasons, but probably a big part is having capacity to diagnose infections and count them.”
Now, with the number of reported cases around the world reaching new highs, the findings should serve as a stark reminder that disease surveillance and tracking remain dangerously inadequate, and that the world may have already overlooked some of the greatest tragedies of the pandemic. Preventing deaths going forward demands a coordinated international effort to contain Covid-19, vaccinate as many people as possible, and monitor the spread of the virus, led by countries with the most resources helping those with the fewest.
Otherwise, an even greater toll may lie ahead.
Almost every part of the world is underreporting Covid-19 deaths
To come up with the new estimate of 6.9 million total Covid-19 deaths so far around the world, the IHME team constructed a model that incorporated observations about the pandemic. They also constructed a baseline estimate of how many deaths there would have been in a world without Covid-19. The team drew on weekly and monthly death records from 56 countries and 198 sub-national locations — city, state, and provincial records — from places like the US and Brazil.
Researchers also drew on previously published death estimates. They then subtracted the anticipated deaths from the actual number of deaths to find the excess mortality stemming specifically from the disease.
Excess mortality is mostly due to deaths directly from Covid-19, but it also includes deaths indirectly caused by the pandemic like people unable or unwilling to receive medical care, a decline in vaccination rates for other diseases, an increase in drug use, and a rise in depression. So researchers tried to correct for these factors to get their Covid-19 death estimate.
It’s a well-worn approach in public health circles and has been used to calculate other health indicators like the global burden of disease.
The model showed that, around the world, more than half of Covid-19-related deaths are not labeled in the official tallies. And the actual number could still be higher.
According to Christopher Murray, the director of IHME, while just about every part of the world missed cases of Covid-19, some countries missed more than others.
“In many parts of the world — sub-Saharan Africa, India, Latin America, differences by state in Brazil and Mexico — you can account for much of the under-reporting because of lower testing rates,” Murray said during a press conference. “But there is this phenomenon — Egypt stands out, as do a number of different countries in Eastern Europe and Central Asia — where these excess mortality rate numbers suggest dramatically larger epidemics than have been reported that cannot be accounted for through testing.”
Egypt has officially reported just over 13,000 Covid-19 deaths, but IHME found its estimated death toll was more than 170,000. It’s not clear why the discrepancy is so large, but it shows Covid-19 epidemics in different countries can be far worse than the death reports reveal.
“We are absolutely, absolutely undercounting deaths,” said Ruth Etzioni, a professor and biostatistician at the Fred Hutchinson Cancer Research Center who was not involved in the study.
IHME’s Covid-19 models missed the mark before, but researchers say they’ve improved
Scientists have also been critical of IHME’s past modeling work during the Covid-19 pandemic.
IHME’s forecasts last spring were criticized for projecting many fewer deaths than actually occurred. In March 2020, the organization projected fewer than 161,000 deaths total in the US. Then in April 2020, the group revised their death toll projections through August to be 60,415, with an uncertainty range between between 31,221 and 126,703 deaths. The projections were out of step with other epidemiological models, which were anticipating far more casualties from Covid-19.
The Trump White House, however, was eager to use the rosy IHME projections as the basis for planning for the pandemic and lifting public health restrictions, as well as a political tool to downplay the severity of Covid-19. “I was furious with [IHME], and I’m still kind of getting over it,” Etzioni said. “In the beginning, it was unacceptably un-rigorous.”
By the end of August 2020, more than 180,000 Americans had died of the disease.
“So far as I can tell, IHME has substantially improved their modeling from the early days of the pandemic,” said Alexey J. Merz, a professor of biochemistry at the University of Washington, in an email. “My major criticisms pertain to those early efforts, and IHME’s ongoing failure to address what went wrong, or to assess the (in my opinion, considerable) damage arising from those flawed estimates.”
Asked about IHME’s track record, Murray explained how his team’s Covid-19 forecasting improved and even outperformed other models. “For example, if you go back to August last year, we were forecasting the winter surge, and nobody else thought there was going to be a winter surge in the United States,” he said. “We spend a lot of time on our model trying to look at what are the long-term drivers so we have been able to pick up these long-term trends quite a bit sooner than others.”
Why the US official count is so low compared to the new analysis
It makes sense that countries with less robust health care systems and fewer resources would struggle to keep track of how many people are dying of Covid-19. But the US, a wealthy country that has a national Covid-19 death reporting system, also missed almost 40 percent of Covid-19 deaths, according to the IHME model.
That’s because while death can seem like a pretty obvious health indicator, the causes of death can be mercurial.
The problems start with the death certificate. Ivor Douglas, chief of the Pulmonary Sciences and Critical Medicine division at the Denver Health Medical Center, explained that death certificates emphasize the primary cause of death, which is the most immediate condition leading to the fatality. Death certificates also have space for secondary and indirect causes.
As the Covid-19 pandemic has revealed, the disease can manifest in myriad ways and leave lasting damage, even in people who had a mild illness.
So a Covid-19 death certificate could list something like a blood clot in the lungs as the primary cause of death, with Covid-19 as a secondary or indirect cause. Whether that specific death is then coded as a Covid-19 fatality could differ depending on the state. That local-level reporting has sometimes become politicized and led to discrepancies in death tolls.
And when Covid-19 first arrived in the US, many health workers didn’t realize what they were dealing with and thus didn’t include it in their paperwork. “I think the preponderance of missed cases were early on in the pandemic,” Douglas said. “Often, certainly early in the pandemic, there was the primary diagnosis without Covid-19 attribution.”
The missing Covid-19 deaths are also another manifestation of the inequities in US society. “If you’re poor, don’t have access [to health care], and die at home, you’re much less likely to have an attribution of Covid pneumonia as a cause of your death than ‘oh, you’re a sad old person with diabetes’ and that was the cause of death,” Douglas said.
That means that the groups that are being most severely harmed by Covid-19 may also be underrepresented in the official numbers. That makes it harder to properly allocate resources like tests, vaccines, and treatment to the most vulnerable people, forcing them to bear an even greater health burden.
“There’s real policy implications, it has political implications, and social justice implications, in my mind,” Douglas said. On the other hand, accurate monitoring could help mitigate the harms of the Covid-19 pandemic, helping health officials figure out not just where to deploy vaccines and treatments, but other factors driving transmission, like crowded living conditions. Intervening before infections begin to spread is what will yield the greatest dividends in containing the disease. “You cannot simply vaccinate your way out of this problem,” Douglas said.
Finding the true toll of Covid-19 is more urgent than ever
Regardless of how high the actual number of deaths is, the devastation of Covid-19 is clear. “Even the reported numbers are so utterly staggering that I’m not even sure doubling it should make us even more horrified,” Nuzzo said.
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Still, the fact that Covid-19 deaths appear so vastly underreported should be a warning that the virus can still take millions more lives, and why containing Covid-19 is imperative for every country in the world. “We should feel more personally threatened by these numbers. And we should recognize it as a societal threat,” Etzioni said.
The devastating Covid-19 outbreak in India is all the more urgent now that multiple variants of Covid-19 that are more transmissible and better able to evade immunity are spreading around the world. As the virus continues to spread, the likelihood of even more dangerous variants arising will grow.
What’s more, the countries that have been reporting lower deaths so far deserve more attention. “Many of us contend that sub-Saharan Africa has been extensively devastated by the pandemic but because of lack of testing medical reporting, it appears as if there has been a relatively minor event there,” Douglas said.
As for countries that have so far been genuinely spared from Covid-19, they must remain vigilant and take active measures to keep the disease at bay. “It may be that they haven’t yet been hit or it could be that we don’t fully understand how they’ve been hit, but I want to put to bed this idea that any country has simply escaped the worst of it,” Nuzzo said. “The countries that have done the best are ones that have been very, very aggressive in responding to it.”
There’s a scene in The West Wing’s second season in which one of the protagonists is told a Chinese satellite is falling to Earth, but no one knew exactly when or where.
“A satellite is crashing to Earth, and NASA sent us a fax?” Donna Moss says, clearly concerned. But few in the show shared her fear, because debris in space often falls out of orbit and is either burned up upon reentry or lands harmlessly somewhere on the planet.
The US government estimates around 200 to 400 tracked objects enter Earth’s atmosphere every year — roughly one a day — out of the 170 million pieces of space debris floating above our heads. The fallen items rarely make news, though, since they usually crash into the ocean, which covers about 70 percent of the Earth’s surface, or sparsely populated areas.
Yet news of a Chinese rocket falling uncontrollably to Earth has awakened the Donna Moss in many of us.
A section of the Long March 5B rocket, which launched China’s new space station into orbit last week, is expected to hit somewhere on the planet either on Saturday or Sunday, experts say. At 10 stories and 18 tons (36,000 pounds), it’s one of the largest items in decades to spiral in an undirected dive toward the Earth.
It could cause serious damage if it hits a major population zone, but so far few governments — especially the one in Beijing — seem overly concerned.
“The probability of this process causing harm on the ground is extremely low,” Chinese Foreign Ministry spokesperson Wang Wenbin said on Friday. The White House and Pentagon, meanwhile, say they’re tracking the rocket and have no plans to shoot it out of the sky.
After speaking with experts, two things have become clear about this episode.
The first is that the idea of a large rocket hurtling toward Earth is understandably scary. It conjures up images of a city devastated by the impact, potentially injuring thousands.
Importantly, the chance of anything like that happening is infinitesimally small — like 1 in a 196.9 million chance small. While there have been a few bad incidents in the past, nothing on that scale has ever happened, and very likely won’t now.
The second is that it’s troubling this scenario could happen in the first place. Why is it possible for China, or any other space-faring nation, to launch massive rockets and let them fall to earth willy-nilly?
The answer to that is policy failure: Despite regulations on space flight and conduct, the issue of rocket reentry is loosely and poorly regulated, so countries cut corners and take their chances that a falling rocket won’t hit anything major.
“We’re in the realm of risk management, and states are willing to swallow the risk,” said Christopher Newman, a professor of space law and policy at Northumbria University in Britain.
But there’s always the more-than-zero chance that their luck runs out and a falling rocket sparks a catastrophe. Experts are unanimous that the falling Chinese rocket is a symptom of a much larger problem that needs solving sooner rather than later.
“If you don’t want any more of this kind of thing to happen, we need the big powers to step up,” said Bleddyn Bowen, a professor of space warfare and policy at the University of Leicester in the UK.
How to stop the next falling rocket
There’s a trope about space that it’s the “Wild West,” a phrase I often catch myself using. But the truth is that there have been rules governing operations in space for decades.
In the Outer Space Treaty of 1967 and Liability Convention of 1972 are guidelines for how to punish a country that lets one of its rockets cause damage on Earth. Basically, those rules say that the offending state can be held liable by the victim nation. So, in this case, if the Chinese rocket were to land in the middle of New York City (which, again, is extremely unlikely to happen), the Biden administration could ask China to pay for damages and demand other recourse.
In other words, this is a state-to-state issue. “If the rocket lands on my house, I can’t go and sue China,” Northumbria’s Newman told me. That’d be UK Prime Minister Boris Johnson’s job to call up Chinese President Xi Jinping.
But that’s really it. There’s nothing in international law to stop any nation from letting any of the 900 rockets currently in orbit from falling in an unplanned way. “This isn’t illegal,” Newman said about the current saga of the Chinese rocket. “There is no sort of regulation on an international level on reentry.”
Individual countries essentially govern themselves when they make plans to launch a rocket into space. If the Chinese government is fine with the plan of an unplanned reentry, then that’s what’ll happen at the end of the mission.
Naturally, such plans cause frustration among space experts. “I think it’s negligent of them,” Jonathan McDowell, an astrophysicist at the Center for Astrophysics in the US, told the New York Times on Thursday. “I think it’s irresponsible.” Last year, in fact, another Chinese Long March 5B rocket burned up and pieces of metal fell onto a few buildings in the Ivory Coast.
But it’s important to remember two things.
First, China — and other leading space-faring nations like the US, Russia, Japan, and the European Union — know that the chance of hitting people or infrastructure is so small that they don’t feel the need to spend extra money and time to plan for a controlled reentry.
Ensuring a rocket splashes into, say, the Pacific Ocean, requires more fuel and staff work, which increases the cost of missions. For most space agencies grappling with small budgets, cutting costs on that part of the operation is worth the risk.
Second, and relatedly, China isn’t the only country taking their chances here; others, including the US, have as well, leading to some scary scenes.
In 1978, a Soviet satellite carrying a nuclear reactor crash-landed in northern Canada and spewed radioactive waste. The next year, the NASA-launched Skylab space station — America’s first one — fell out of orbit, with parts landing in the Indian Ocean and in Western Australia, though luckily hurting no one.
“Bad behavior was quite typical by the Americans and Soviets during the space race,” said Leicester’s Bowen. “Those who live in glass houses should not throw stones,” he said of current complaints about the Chinese rocket.
While there are more safety measures now and technology has improved, experts say the main problem is still that space law is too lax on this issue. They point to the Ivory Coast incident last year, where the country decided not to seek recourse from China, potentially out of the desire not to anger a key economic partner.
So what has to change?
Experts say countries like China, the US, and others should leverage this moment and work through the United Nations to regulate rocket reentry. They should compel space programs to spend more to ensure their rockets land far away from people, and even wildlife, when possible. Even if the risk of a calamity is extremely low today, the fact that it’s more than zero is already too high.
“If this is good for anything, it’s an opportunity for everyone to take ownership of space as a domain of human activity and to want a say in how it’s governed,” said Northumbria’s Newman. “We’re now at the stage where this is generating concern.”
But until there’s political will for such action — and governments take the rocket reentry problem seriously — we’ll have more Chinese-rocket-type scares.
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While here in the US some are tentatively removing their masks and resuming small outdoor gatherings, others around the world are searching for air. In India, people need oxygen, and they need it now.
Last week, Covid-19 became India’s No. 1 killer. One million people in a country with a population of 1.3 billion are predicted to die of Covid-19 by August. As of May 7, 150 people were reportedly dying every hour, and while 29 million have been fully vaccinated there, vaccines are not what is most urgently needed right now.
When people are sick with Covid-19, many have trouble breathing, and the most important treatment is oxygen. But in India there is debate over whether there’s an oxygen shortage or a problem with accessing the existing supply.
Regardless, many people can’t get the lifesaving treatment they need just to breathe. Some oxygen systems, whether for hospitals or for individuals, require refills. Global systems of production, movement of goods, and tariffs all regulate who can get oxygen. In this case, people waiting outside hospitals are dying for oxygen, and this is perhaps why some in India are calling death from lack of oxygen a genocide.
The shortage of oxygen in India is not an unusual event. It is a reminder of interconnected networks that regulate production and supply, and that inequality means life for some and death for others.
Calls for solutions to the oxygen shortage from India’s top court and elsewhere continue, as do urgent messages like #SOSoxygen on Twitter and other social media where people list what they need.
As Ruchit Nagar, founder of Khushi Baby, an Indian NGO headquartered in Udaipur, Rajasthan, explains, “smaller hospitals are pleading, saying, ‘We only have a day of oxygen left and [many] people at risk of dying if we don’t get it in 24 hours.’ In some cases, that cry for help is met on time, but in other cases people literally run out of oxygen. … There’s no easy solution.”
All this is set against a backdrop of climate change, environmental racism, and poverty causing a scarcity of clean air. Poor air quality in India and elsewhere causes childhood asthma and adult lung disease. Housing shortages, overcrowding, and inadequate access to sanitation infrastructure contribute to fine particulate matter, raising risks for poor outcomes from Covid-19 and even increase the likelihood that the virus will spread. This combined with the lack of oxygen creates a dire threat.
As a group of researchers, writers, and medical providers in the US, we are watching these events unfold with grief, horror, and a painful sense of déjà vu from when the US experienced its own horrible surges in hospitalizations and deaths. This will not be the last crisis. But the steps we take to stem the suffering and devastation will inform how we handle future Covid-19 surges and other disasters in other countries. Today the lesson is about oxygen, something none of us can live without.
Why some Covid-19 patients need oxygen
Oxygen is a critical resource because Covid-19 can inflame the lungs and sometimes fill them with fluid, making it hard to breathe. Even asymptomatic people with Covid-19 can have signs of lung infections in X-rays and CT scans that may contribute to a sudden worsening of symptoms. The virus may also bind to hemoglobin, the protein in red blood cells that transports oxygen through the blood and delivers it to the body.
A person’s oxygen level should be 95 to 100 percent at sea level, though patients with chronic lung problems, like emphysema, can live at an oxygen level of 88 to 92 percent. But the National Institutes of Health considers people with Covid-19 who have oxygen saturation levels less than 94 percent to have “severe illness.”
Why? Lower oxygen levels force the body to work harder to supply enough oxygen to vital organs like the heart and brain. Death from Covid-19 is often from hypoxia — a form of tissue suffocation where the lungs are unable to absorb enough oxygen from the air being breathed — or respiratory failure, when the body is unable to get enough oxygen and basically exhausts itself trying. By contrast, early access to oxygen can help prevent patients from becoming critically ill.
How we get oxygen for medical use
The New York Times recently reported on a looming global oxygen crisis, but there were concerns about India’s oxygen supplies dating back to September.
In areas with more resources, oxygen is purified off-site into a liquid form, transported by trucks with massive tanks, and stored in hospitals. This oxygen is then delivered as a gas through piping built into hospitals. Patients receive oxygen through nasal cannulas (plastic tubes that go directly into their noses), masks on their faces, or ventilators.
Some remote hospitals have small plants that can continuously purify oxygen on-site. However, many lower-income communities globally are dependent on smaller individual tanks that need to be refilled. This is the most expensive form of oxygen delivery, costing about 10 times as much as the large-scale liquid version.
Individuals can purchase oxygen tanks, or “cylinders,” which don’t require electricity for use but need to be refilled when they are empty. Tanks last anywhere from less than one hour to nearly 40 hours, depending on how much oxygen the person needs.
Another option — one people are desperately seeking in India — is oxygen concentrators, smaller machines that can provide oxygen to one or a few patients. They are easy to use, are portable, can be placed near bedsides in homes and clinics, and can make oxygen on the spot from air and water. They are ideal for less severe cases of Covid-19.
Since they draw oxygen from the surrounding air, concentrators can cut down the need for constant refilling of oxygen cylinders and free up supply for more severely ill patients. They require batteries or an electrical source, but some designs can supply oxygen 24/7 for five years or more.
The response so far isn’t enough
The Indian government and the international community have been scrambling to increase the supply of available oxygen through multiple means. By the beginning of May, New Delhi’s daily oxygen demand surged to 976 metric tons, more than double its current supply.
Other countries have been donating liquid oxygen, and the Indian government announced plans to dramatically expand oxygen manufacturing abilities, but as of April 24 there were only 33 oxygen plants out of 150 requested. Hence, the majority of the country is relying on the more expensive, single-use forms of oxygen.
The biggest problem may not be the supply itself as much as access. Most oxygen production is on the coast, and special tankers are required to deliver it in larger quantities to population centers. The Indian Army and the Railways Ministry are assisting with the logistics of transporting oxygen tankers to the worst-hit areas.
Previously, hospitals might need a refill once a week, but now they need it daily. Unfortunately, it can take six to seven days for one tanker to make a round trip, and with increased demand, government officials and oxygen plant leaders expressed concerns about tanker shortages during the surge as well.
India temporarily exempted importing personal oxygen concentrators from customs clearance until July 31, paving the way for efficient donation and capacity for better crisis response. While the country’s finance ministry removed both customs fees and the goods and services tax (GST) for oxygen cylinders, the GST of 12 percent — down from 28 percent — still applies to oxygen concentrators, priced at $550 to $4,000. The courts are arguing that concentrators should be treated the same as oxygen cylinders and the GST removed.
With lockdowns creating barriers, raw materials imports are challenging. On top of that, the fractious to and fro between the central and local government on supply and demand worsens oxygen delivery gaps.
Meanwhile, on social media, families and communities are using #SOSOxygen and #OxygenShortage to make requests. With over half of India living without access to the internet, these requests are coming from those with the resources to ask, and they’re taking a significant risk to do so.
In Uttar Pradesh, India’s most populous state, individuals and hospitals can be punished for speaking out about the oxygen shortage, and at least one person has been arrested for tweeting a request for an oxygen cylinder, though this hasn’t stopped people from turning to this last resort.
“Some of the damage can be mitigated, but it’s a bleak situation,” says Nagar. “We’re not going to be able to stop the tsunami. We can try to save some lives, but the tsunami is going to hit. It already has.”
A quicker response to India’s crisis requires flexibility and knowledge from the ground
Today’s oxygen crisis in India feels similar to last year’s personal protective equipment (PPE) shortage in the US and Europe. But wealthier countries are no longer in desperate need of supplies. This gives the US an opportunity to renew its commitment to global health.
More oxygen doesn’t solve the pandemic, but it does save lives. And, in partnership with substantial prevention measures, it is part of a toolkit of strategies to stem the surge.
Technology has facilitated access to some oxygen and other supplies, including crowdsourcing of cylinders and hospital beds. Rural areas with high cellphone use now play public service announcements before each call encouraging the use of masks. And Nagar explains that some local and international organizations, like Khalsa Aid, “have been procuring oxygen concentrators, and some have been able to set up a drive-through situation, where … you can get access to a cylinder or refill your own.”
Perhaps most important to long- and short-term solutions is the ability to listen to on-the-ground needs and work with organizations, like Give India, that are already using locally appropriate tools to address the problems.
Effective international collaboration, like waiving regulations to speed up thoughtful production, helps. So does shipping and distributing the right kinds of technologies for acute care, such as oxygen concentrators, suction tubing, pulse oximeters, antibiotics, and PPE.
China and India, often at odds with border disputes, are collaborating to increase the supply of oxygen concentrators, Nagar says. The World Health Organization Covid-19 Essential Supplies Forecasting Tool can be used for country-level detailed supply calculations. Khushi Baby is also helping with data collection to predict the demand for oxygen and other supplies in upcoming weeks, and it is part of a network of NGOs collaborating to bring support where it is needed most.
The need for global solutions
The surge in India highlights our global interconnectedness, and the need for both global and local solutions to stem the pandemic. India was previously the primary manufacturer of vaccines but now is desperately trying to re-import them.
Meanwhile, other countries are waiting on contracts from India that can’t be filled. At the same time, the new variants that appear with each new surge of cases put all of us at risk, including the variant recently found in four states in India. These variants may lower the efficacy of our vaccines over time. India’s problem is everyone’s problem.
Gaurab Basu, a physician and global health leader at Harvard University, explains that we must shift from thinking about charity to thinking about justice, “not chasing global tragedy with oxygen containers.” He adds that our global experience right now parallels “the lack of federal government in the US for much of 2020 and how the states suffered from that.”
Global leaders and local health care workers can continue to improve triage and clinical care driven by local data. This, coupled with interventions like screening, testing, contact tracing, quarantining, and public service announcements focused on individual behaviors, provides a comprehensive, proactive approach to save lives.
These courses of action pave the way for a proactive and collaborative response to disasters in the future. There is a need for interconnected global systems designed to allow for listening to what’s needed on the ground. And right now, that’s oxygen.
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Lisa J. Hardy is an associate professor of medical anthropology and director of the Social Science Community Engagement Lab in northern Arizona conducting international research on Covid-19.
Lawrence Weru is a consultant and digital storyteller who illustrates the sciences for a more just and sustainable world.
Nazia Sadaf is a family physician at PISES Riyadh, integrating patient care with artificial intelligence as a Forbes Ignite Impact fellow and change maker.
Jennifer Kasper is an assistant professor of Global Health and Social Medicine at Harvard Medical School with expertise in health and human rights issues in India.
Francesca Decker is a family physician with a master’s in public health who works in student health at Cornell University.